Pang et al. BMC Infectious Diseases (2017) 17:428 DOI 10.1186/s12879-017-2525-3
RESEARCH ARTICLE
Open Access
Assessing changes in knowledge, attitude and practices on dengue diagnosis and management among primary care physicians after the largest dengue epidemic in Singapore Junxiong Pang1,2*, Zoe Jane-Lara Hildon2,3,4, Tun Linn Thein1, Jing Jin1 and Yee Sin Leo1,2,5,6
Abstract Background: Dengue results in high morbidity and mortality globally. The knowledge, attitude and practices (KAP) of dengue management, including diagnosis, among primary care physicians (PCPs) are important to reduce dengue transmission and burden. However, there is a lack of understanding on the impact of dengue epidemic on dengue management. Hence, the aim of this study is to examine the changes in KAP on dengue management among PCPs before and after the largest dengue epidemic in 2013 in Singapore. Methods: Surveys were mailed to 2000 and 1514 PCPs registered under the Singapore Medical Council in March of year 2011 and 2014, respectively. Survey data were then collected between April and June of that year. Chi-square or Fisher’s exact test was used for comparing categorical variables. A multivariate logistic regression model was implemented to determine independent factors for frequent use of dengue diagnostic tests (DDTs). All tests were conducted at 5% level of significance. Adjusted odds ratio and corresponding 95% confidence intervals were reported, where applicable. Qualitative data were descriptively coded for themes and analysis. Results: Among PCPs surveyed in 2011 and 2014, 89.9% and 86% had good knowledge on dengue management respectively. The usage of DDTs had increased significantly in 2014 (N = 164;56%) as compared to 2011 (N = 107;29. 5%) in both private and public clinics (p < 0.001). Dengue Duo point-of-care test (POCT) kits was independently associated with frequent use of DDTs (adjusted odds ratio = 2.15; 95% confidence interval = 1.25–3.69). There was a significant reduction in referral of dengue patients to hospital (31.4% in 2011; 13.3% in 2014; p < 0.001), and a significant increase in frequency of clinic follow-ups (18.4% in 2011; 28.5% in 2014; p = 0.003). One key theme highlighted was that dengue management can be improved with availability of POCT kit, better awareness of the disease and any revised clinical guidelines. Conclusion: The knowledge on dengue management remained high, while the attitude and practices, particularly on the usage of DDTs improved significantly after a large epidemic. Furthermore, PCPs had more confident in managing dengue patients in primary care settings and in educating patients on the importance of vector control and dengue warning signs to reduce dengue transmission and burden. Keywords: Dengue epidemic, Primary care, Dengue management, Dengue diagnosis, Knowledge, Attitude, Practices
* Correspondence: [email protected] 1 Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 144 Moulmein Road, Singapore 308089, Singapore 2 Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Pang et al. BMC Infectious Diseases (2017) 17:428
Background Dengue, one of the major global burdens, is estimated to affect at least 50 million people annually [1]. Dengue haemorrhagic fever (DHF) and Dengue shock syndrome (DSS) are severe clinical manifestations for dengue infection in both adult and children. Identifying the disease early and predicting the possible outcomes effectively is a leading concern for Public Health specialists managing the disease [2] Dengue fever (DF) is endemic in the tropical and subtropical regions, including Singapore [2]. Dengue was first reported in Singapore in the early 1960 [3]. Since 1969, with the implementation of vector control and surveillance, public health education and law enforcement, there has been a general decline in disease incidence, until in 1990 when dengue began to surge again [4]. Since then, Singapore has faced several dengue epidemic. Spikes have been recorded in 2005 and 2007 with 14,209 and 8826 cases respectively [5]. The largest dengue epidemic was experienced in the year 2013 with 22,170 reported dengue cases with eight deaths [6]. In Singapore, the occurrence of DF and DHF are influenced by several factors such as lowered herd immunity and virus transmission outside the home by Aedes mosquitoes, which potentially resulted in the resurgence of dengue incidences among adult population [7]. In 1997, the World Health Organization introduced dengue management guidelines for diagnosis, treatment, prevention and control [8]. A revised edition was released in 2009 with updated information for better clinical management, vector management and laboratory diagnosis [9]. Dengue virus infection may be asymptomatic or symptomatic that may lead to unpredictable severe outcomes such as death. In the three largest outbreak clusters in Singapore, it was revealed that 73.2% of residents with recent infection were asymptomatic [5]. Hence, early detection of these dengue cases and monitoring of disease severity are important parts of dengue management to reduce dengue transmission and burden. Moreover, to avoid over-hospitalization during an epidemic, it is important to have a system not only for early detection but also effective outpatient monitoring. Since the development of Dengue Duo POCT kit [10], there were many clinical validation studies performed such as the SD Dengue Duo POCT kit (Standard Diagnostics, Inc., Gyeonggi-do, Korea) with sensitivities and specificities ranging from 75.5–92.9% and 88.8–100% respectively using frozen serum or plasma samples [11–14]. This commercially available assay uses whole blood to obtain dengue positivity result within 30 min of patient presentation. In 2013, SD Dengue Duo POCT kit was also validated in Singapore with sensitivity and specificity of 93.9% and 92.0% respectively [15], with significant reduction (from estimated four hours to an hour) in the time
Page 2 of 10
required from patient presentation to appropriate clinical management in a tertiary hospital. This kit, which includes both dengue NS1 antigen and dengue IgM & IgG antibody detection, is likely to enhance early diagnosis of dengue and reduce dengue burden at the primary healthcare settings. A good understanding of the changes in KAP of the dengue management among the PCPs will be important to reduce dengue burden. Even though there were two cross-sectional KAP studies focusing on the dengue management of PCPs in Southern Vietnam [16] and Southern Taiwan [17], there is still a lack of understanding on the changes of KAP after a large dengue epidemic. Therefore the aims of this study were to (1) Examine changes in primary care physicians knowledge, attitude and practices, in particular on the usage of dengue diagnostic tests and related clinical practices; (2) Enquire about their experience on using the POCT kit; (3) Gather recommendations for improved service delivery in patient diagnostics and clinical care management to facilitate reduction in dengue burden.
Methods Study design
Surveys were mailed to 2000 and 1514 PCPs registered under the Singapore Medical Council in March of year 2011 [18] and 2014, respectively. Survey data were then collected back between April and June of that year. The survey form was developed by clinical researchers and was piloted prior to the actual survey. A total of 364 (18.3%) and 293 (19.4%) surveys were mailed back in 2011 and 2014, respectively. We compared survey data using baseline data collected in 2011 [18] and a followup survey in 2014. The survey included open-ended questions enquiring about the usage experience and/or perception of the new POCT kit introduced in 2014 to facilitate dengue diagnosis. Survey questionnaire
The questionnaire was designed with four parts. They were (1) practitioner demographics (gender, age, type of practice and qualification), (2) dengue management – including related knowledge, dengue diagnostic practices, and clinical care; (3) attitudes toward POCT and (4) responses to the dengue epidemic in 2013. The baseline survey included 25 multiple-choice questionnaires [18]. However, only 18 of these questions were retained in the 2014 survey so that meaningful comparisons focusing on dengue management can be performed (Additional file 1). In relation to repertoires of disease management, participants were asked about their preferred method of dengue diagnosis, the level clinical care of confirmed patients, and their knowledge on dengue clinical guidelines. The dengue warning signs recommended by the World Health Organization used to classify Dengue into levels of severity
Pang et al. BMC Infectious Diseases (2017) 17:428
was assessed [1]. These warning signs include: abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, bleeding/mucosal bleeding, drowsiness, fatigue, lethargy, breathlessness, increase in haematocrit concurrent with rapid decrease in platelet count and hepatomegaly. Participants were asked about their awareness of the warning signs and to list down three common ones. In the follow-up survey in 2014, participants were asked about their awareness on rapid Dengue POCT, their level of interest in using it and any perceived challenges/benefits if they have experience using it. Two open-ended questions were designed to seek participants’ opinion and experience about surge management, and how participants had managed the 2013 epidemic and the changes in dengue management after these dengue epidemics. Analytic methods
Analysis was performed with consideration of both the quantitative and qualitative data gathered in the survey. For the quantitative analyses, the data were stratified by type of practice, i.e. government subsidized polyclinic, private practice. Chi-square or Fisher’s exact test was used for comparing categorical variables. A multivariate logistic regression model was implemented to determine independent factors for frequent use of DDTs. All tests were conducted at 5% level of significance. We reported adjusted odds ratio and corresponding 95% confidence intervals where applicable.
Page 3 of 10
All statistical analyses were performed using SPSS Version 16 (SPSS Inc., Chicago, IL). Qualitative data were descriptively coded for themes on the topics of the experience of using the POCT kit, the management of dengue epidemics and changes in dengue management after dengue epidemic. NVivo 10 software Version 10, 2012 (QSR International Pty Ltd.) was used to manage the textual data.
Results Demographics characteristics of PCPs surveyed in 2011 and 2014
A total of 364 PCPs participated (18.3% response rate) in the survey in 2011 [18]. A total of 293 PCPs participated (19.4% response rate) in the survey in 2014 (Table 1). Among these, majority were male (N = 157; 53.6%), and were pre-dominantly in the age-group of 41–60 years old (N = 185; 63.1%) and from the private sector (N = 206; 70.3%). There was significantly lesser male PCPs (p = 0.046) in year 2014 (N = 157; 53.6%) than year 2011 (N = 223; 61.3%). There were significantly more PCPs in the 41–60 years old group, but lesser in the above 60 years old group (p < 0.0001) in the survey year 2014 (N = 185; 63.1% & N = 26; 8.9% respectively) than year 2011 (N = 185; 50.8% & N = 67; 18.4% respectively). The proportion of PCPs with post-graduate degree qualifications was significantly higher in survey year 2014 (N = 158; 53.9%) than in 2011 (N = 124; 34.1%; p < 0.001; Table 1).
Table 1 Demographics of primary care physicians Years
2011 N = 364 (%)
2014 N = 293 (%)
P value
CFPS 2011a N = 1400 (%)
0.046
(60)
Gender Male
223 (61.3)
157 (53.6)
D.N.P.
3 (0.8)
1 (0.3)
111 (30.5)
82 (28.0)
Age 21–40 years 41–60 years
185 (50.8)
185 (63.1)
61 years or above
67 (18.4)
26 (8.9)
D.N.P.
1 (0.3)
0
(58) for
RESEARCH ARTICLE
Open Access
Assessing changes in knowledge, attitude and practices on dengue diagnosis and management among primary care physicians after the largest dengue epidemic in Singapore Junxiong Pang1,2*, Zoe Jane-Lara Hildon2,3,4, Tun Linn Thein1, Jing Jin1 and Yee Sin Leo1,2,5,6
Abstract Background: Dengue results in high morbidity and mortality globally. The knowledge, attitude and practices (KAP) of dengue management, including diagnosis, among primary care physicians (PCPs) are important to reduce dengue transmission and burden. However, there is a lack of understanding on the impact of dengue epidemic on dengue management. Hence, the aim of this study is to examine the changes in KAP on dengue management among PCPs before and after the largest dengue epidemic in 2013 in Singapore. Methods: Surveys were mailed to 2000 and 1514 PCPs registered under the Singapore Medical Council in March of year 2011 and 2014, respectively. Survey data were then collected between April and June of that year. Chi-square or Fisher’s exact test was used for comparing categorical variables. A multivariate logistic regression model was implemented to determine independent factors for frequent use of dengue diagnostic tests (DDTs). All tests were conducted at 5% level of significance. Adjusted odds ratio and corresponding 95% confidence intervals were reported, where applicable. Qualitative data were descriptively coded for themes and analysis. Results: Among PCPs surveyed in 2011 and 2014, 89.9% and 86% had good knowledge on dengue management respectively. The usage of DDTs had increased significantly in 2014 (N = 164;56%) as compared to 2011 (N = 107;29. 5%) in both private and public clinics (p < 0.001). Dengue Duo point-of-care test (POCT) kits was independently associated with frequent use of DDTs (adjusted odds ratio = 2.15; 95% confidence interval = 1.25–3.69). There was a significant reduction in referral of dengue patients to hospital (31.4% in 2011; 13.3% in 2014; p < 0.001), and a significant increase in frequency of clinic follow-ups (18.4% in 2011; 28.5% in 2014; p = 0.003). One key theme highlighted was that dengue management can be improved with availability of POCT kit, better awareness of the disease and any revised clinical guidelines. Conclusion: The knowledge on dengue management remained high, while the attitude and practices, particularly on the usage of DDTs improved significantly after a large epidemic. Furthermore, PCPs had more confident in managing dengue patients in primary care settings and in educating patients on the importance of vector control and dengue warning signs to reduce dengue transmission and burden. Keywords: Dengue epidemic, Primary care, Dengue management, Dengue diagnosis, Knowledge, Attitude, Practices
* Correspondence: [email protected] 1 Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 144 Moulmein Road, Singapore 308089, Singapore 2 Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Pang et al. BMC Infectious Diseases (2017) 17:428
Background Dengue, one of the major global burdens, is estimated to affect at least 50 million people annually [1]. Dengue haemorrhagic fever (DHF) and Dengue shock syndrome (DSS) are severe clinical manifestations for dengue infection in both adult and children. Identifying the disease early and predicting the possible outcomes effectively is a leading concern for Public Health specialists managing the disease [2] Dengue fever (DF) is endemic in the tropical and subtropical regions, including Singapore [2]. Dengue was first reported in Singapore in the early 1960 [3]. Since 1969, with the implementation of vector control and surveillance, public health education and law enforcement, there has been a general decline in disease incidence, until in 1990 when dengue began to surge again [4]. Since then, Singapore has faced several dengue epidemic. Spikes have been recorded in 2005 and 2007 with 14,209 and 8826 cases respectively [5]. The largest dengue epidemic was experienced in the year 2013 with 22,170 reported dengue cases with eight deaths [6]. In Singapore, the occurrence of DF and DHF are influenced by several factors such as lowered herd immunity and virus transmission outside the home by Aedes mosquitoes, which potentially resulted in the resurgence of dengue incidences among adult population [7]. In 1997, the World Health Organization introduced dengue management guidelines for diagnosis, treatment, prevention and control [8]. A revised edition was released in 2009 with updated information for better clinical management, vector management and laboratory diagnosis [9]. Dengue virus infection may be asymptomatic or symptomatic that may lead to unpredictable severe outcomes such as death. In the three largest outbreak clusters in Singapore, it was revealed that 73.2% of residents with recent infection were asymptomatic [5]. Hence, early detection of these dengue cases and monitoring of disease severity are important parts of dengue management to reduce dengue transmission and burden. Moreover, to avoid over-hospitalization during an epidemic, it is important to have a system not only for early detection but also effective outpatient monitoring. Since the development of Dengue Duo POCT kit [10], there were many clinical validation studies performed such as the SD Dengue Duo POCT kit (Standard Diagnostics, Inc., Gyeonggi-do, Korea) with sensitivities and specificities ranging from 75.5–92.9% and 88.8–100% respectively using frozen serum or plasma samples [11–14]. This commercially available assay uses whole blood to obtain dengue positivity result within 30 min of patient presentation. In 2013, SD Dengue Duo POCT kit was also validated in Singapore with sensitivity and specificity of 93.9% and 92.0% respectively [15], with significant reduction (from estimated four hours to an hour) in the time
Page 2 of 10
required from patient presentation to appropriate clinical management in a tertiary hospital. This kit, which includes both dengue NS1 antigen and dengue IgM & IgG antibody detection, is likely to enhance early diagnosis of dengue and reduce dengue burden at the primary healthcare settings. A good understanding of the changes in KAP of the dengue management among the PCPs will be important to reduce dengue burden. Even though there were two cross-sectional KAP studies focusing on the dengue management of PCPs in Southern Vietnam [16] and Southern Taiwan [17], there is still a lack of understanding on the changes of KAP after a large dengue epidemic. Therefore the aims of this study were to (1) Examine changes in primary care physicians knowledge, attitude and practices, in particular on the usage of dengue diagnostic tests and related clinical practices; (2) Enquire about their experience on using the POCT kit; (3) Gather recommendations for improved service delivery in patient diagnostics and clinical care management to facilitate reduction in dengue burden.
Methods Study design
Surveys were mailed to 2000 and 1514 PCPs registered under the Singapore Medical Council in March of year 2011 [18] and 2014, respectively. Survey data were then collected back between April and June of that year. The survey form was developed by clinical researchers and was piloted prior to the actual survey. A total of 364 (18.3%) and 293 (19.4%) surveys were mailed back in 2011 and 2014, respectively. We compared survey data using baseline data collected in 2011 [18] and a followup survey in 2014. The survey included open-ended questions enquiring about the usage experience and/or perception of the new POCT kit introduced in 2014 to facilitate dengue diagnosis. Survey questionnaire
The questionnaire was designed with four parts. They were (1) practitioner demographics (gender, age, type of practice and qualification), (2) dengue management – including related knowledge, dengue diagnostic practices, and clinical care; (3) attitudes toward POCT and (4) responses to the dengue epidemic in 2013. The baseline survey included 25 multiple-choice questionnaires [18]. However, only 18 of these questions were retained in the 2014 survey so that meaningful comparisons focusing on dengue management can be performed (Additional file 1). In relation to repertoires of disease management, participants were asked about their preferred method of dengue diagnosis, the level clinical care of confirmed patients, and their knowledge on dengue clinical guidelines. The dengue warning signs recommended by the World Health Organization used to classify Dengue into levels of severity
Pang et al. BMC Infectious Diseases (2017) 17:428
was assessed [1]. These warning signs include: abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, bleeding/mucosal bleeding, drowsiness, fatigue, lethargy, breathlessness, increase in haematocrit concurrent with rapid decrease in platelet count and hepatomegaly. Participants were asked about their awareness of the warning signs and to list down three common ones. In the follow-up survey in 2014, participants were asked about their awareness on rapid Dengue POCT, their level of interest in using it and any perceived challenges/benefits if they have experience using it. Two open-ended questions were designed to seek participants’ opinion and experience about surge management, and how participants had managed the 2013 epidemic and the changes in dengue management after these dengue epidemics. Analytic methods
Analysis was performed with consideration of both the quantitative and qualitative data gathered in the survey. For the quantitative analyses, the data were stratified by type of practice, i.e. government subsidized polyclinic, private practice. Chi-square or Fisher’s exact test was used for comparing categorical variables. A multivariate logistic regression model was implemented to determine independent factors for frequent use of DDTs. All tests were conducted at 5% level of significance. We reported adjusted odds ratio and corresponding 95% confidence intervals where applicable.
Page 3 of 10
All statistical analyses were performed using SPSS Version 16 (SPSS Inc., Chicago, IL). Qualitative data were descriptively coded for themes on the topics of the experience of using the POCT kit, the management of dengue epidemics and changes in dengue management after dengue epidemic. NVivo 10 software Version 10, 2012 (QSR International Pty Ltd.) was used to manage the textual data.
Results Demographics characteristics of PCPs surveyed in 2011 and 2014
A total of 364 PCPs participated (18.3% response rate) in the survey in 2011 [18]. A total of 293 PCPs participated (19.4% response rate) in the survey in 2014 (Table 1). Among these, majority were male (N = 157; 53.6%), and were pre-dominantly in the age-group of 41–60 years old (N = 185; 63.1%) and from the private sector (N = 206; 70.3%). There was significantly lesser male PCPs (p = 0.046) in year 2014 (N = 157; 53.6%) than year 2011 (N = 223; 61.3%). There were significantly more PCPs in the 41–60 years old group, but lesser in the above 60 years old group (p < 0.0001) in the survey year 2014 (N = 185; 63.1% & N = 26; 8.9% respectively) than year 2011 (N = 185; 50.8% & N = 67; 18.4% respectively). The proportion of PCPs with post-graduate degree qualifications was significantly higher in survey year 2014 (N = 158; 53.9%) than in 2011 (N = 124; 34.1%; p < 0.001; Table 1).
Table 1 Demographics of primary care physicians Years
2011 N = 364 (%)
2014 N = 293 (%)
P value
CFPS 2011a N = 1400 (%)
0.046
(60)
Gender Male
223 (61.3)
157 (53.6)
D.N.P.
3 (0.8)
1 (0.3)
111 (30.5)
82 (28.0)
Age 21–40 years 41–60 years
185 (50.8)
185 (63.1)
61 years or above
67 (18.4)
26 (8.9)
D.N.P.
1 (0.3)
0
(58) for
